Discuss about the Different Concepts Related To Musculoskeletal Assessment.
The current study focuses on the different concepts related to musculoskeletal assessment. There are different frameworks which have been designed for the purpose. One such theory of practice has been suggested by Cranage et al. in the year 2016, which mainly focuses upon lower limb assessment of children aged 0-18 years. It came to be known as Gait and Lower Limb Observation of Paediatrics (GALLOP). It had been increasingly used by Australian podiatrists and physiotherapists for assessment of the movement patterns of a child through the development of evidence-based proforma. This is because before GALLOP there had been no standardised recording proforma. The GALLOP proforma over here consists of number of parameters which could be used for the gathering of information regarding the mobility patterns of the child such as observation of functional tasks such as throwing the ball, catching the ball, sport-specific activities etc (Cranage, Banwell & Williams, 2016). Additionally, the quality of movements is accessed that as if the child performs movements clumsily or smoothly. Further, the GAIT assessment in a child is conducted for movement across a number of positions such as head and neck position, trunk or torso position, arm swing, hip rotation, knee position, foot progression angle. Therefore, apart from these some of the additional details of the patient such as birth history; age of skill acquisition such as sitting, crawling, walking, jumping; ability to perform basic activities such as squatting, skipping, running, hopping etc are accessed. In case the child complains of pain while performing the basic activities, it is measured on a scale of 1-10, where 0 refers to ‘no hurt’ and 10 refers to ‘hurts worst’.
The findings from the assessment could be used by the clinician for implementation of other assessment tools. The findings from the assessment present important neurological findings which can be used for the development of effective treatment methods. Additionally, the abnormal findings from the assessment could be used for conducting further tests and analysis in order to accurately diagnose the clinical condition present within the patient. The GALLOP provides a comprehensive collection of questions and measures. However, as argued by Barton et al. (2016), the results of the clinical assessment tests could be subjected to biases. Therefore, the accurate presentation of the results depends upon the level of expertise of the clinical practitioner. Therefore, based upon the level of expertise possessed by the physician, it could further decide which clinical signs should be included in the final presentation of the results and which of the clinical signs could be omitted. For example, the child suffering from pain in multiple joints may require the use of paediatric gait arms and legs tool (pGALS) tool. Additionally, Bruninks-Oseretsky test of motor proficiency could be used for in-depth analysis of the gross motor skills of the child (Cranage, Banwell & Williams, 2016). However, a number of limitations are faced over here as a number of components included in the proforma do not have reliable data. The lack of technology may affect the quality of data. The accuracy of the results is also based on the level of expertise possessed by the healthcare professionals.
The GALLOP could be divided into separate domains based upon the different question themes used throughout the assessment. The questions themes have been divided into – pre and postnatal history, child’s developmental milestone or acquisition of skills, observation of involvement in relationship to age, recording of other neurological observations, assessment of lower limb. In this respect, the pre and postnatal recordings take all the factors such as pregnancy complications, gestation period, delivery method, birth weight of child family history of foot and leg problems into consideration. The developmental milestones take into consideration the age at which the child starts walking, running, jumping; the presence checks the involvement and the ability of the child at each stage, i.e. the ability to sit, stand, walk, run etc. It is at this stage that the quality of body movement is checked, that is the symmetry and coordination while conducting complex activities such as throwing, catching, kicking a ball etc. The neurological assessments are important to rule out the presence of Gower’s sign within the patient. It is particularly important at the stage when the child learns to sit upright or stand, as delay in such activities could signify the presence of neurological abnormalities (Pratt & Sanner, 2016). Lastly, the assessment of the lower limb through activities such as hip rotation, abductory twist along with foot progression angle could help in ruling out any anomalies present in the lower limb movement patterns of the child.
Distance running has been seen to be an effective method to improve fitness. However, as suggested by Landreneau, Watts, Heitzman and Childers (2014), it is often associated with high risk of lower limb injuries. Therefore, variation in running techniques has been found to minimise the injury to tissues of the lower limb by alternating between the pressures exerted over the forefoot and rearfoot. In rearfoot strike (RFS) the heel of the foot lands on the ground surface first, whereas in forefoot strike (FFS) the ball of the foot touches the ground surface first. The running has been associated with a number of different injuries such as 56.6% of the athletes sustained Achilles tendon overuse injury, 46.4% reported anterior knee pain, 12.7% reported plantar fasciitis (Landreneau, Watts, Heitzman & Childers, 2014). Training errors could also lead to some of these injuries. It has been seen that ground reaction forces (GRF) to running exceeds three times to that of walking (runnersworld.com, 2018).
As mentioned by Landreneau, Watts, Heitzman and Childers (2014), the FFS may reduce the probability of injuries alongside including reduced absorption of energy at the knee, providing faster running pace and better running economy. As suggested by Vannatta, Kernozek and Gheidi (2017), the type of foot strike pattern utilized alters the running mechanics by changing the GRFs and lower limb kinematics. The shift between the different running patterns changes the type of muscle activity. Thus, the Electromyography (EMG) measurements of the magnitude of muscular activity may play a pivotal role in understanding potential injury mechanisms. A good understanding of the muscle activity during FFS and RFS can help the clinicians in determining the cause of injury and develop appropriate therapeutic interventions.
In this respect, a number of evidence-based studies have been conducted to find out the sole impact of rearfoot strike versus forefoot strike. Under any conditions, the FFS have been more favoured compared to RFS as it improves the energy economy, reduces the impact of GRFs and reduces the risk or the extent of injury. Therefore, in order to find the efficacy of the rearfoot versus the forefoot an experiment had been conducted in the MIT. From the results of the experiment, there has been discrepancy in the use of the rearfoot and the forefoot where some have stated that no significant difference lies in switching from the rearfoot to the forefoot (runnersworld.com, 2018). The study conducted at MIT places more importance upon the natural tendency shifting of the body. The experiment was conducted with two groups of veteran runners which are the habitual forefoot runners and the habitual rearfoot runners. It was found that during experimentation most of the rearfoot runners became less economical as they were transferred to forefoot. In order to arrive at a definite theory most of the habitual forefoot runners were transferred to rearfoot for a while on which less VO2 was recorded for them (Bixby & Puig, 2018). Here, vo2 refers to individual oxygen consumption during intense exercise.
A number of limitations were faced over here such as the participants were allowed to use their own footwear. The use of comfortable footwear may introduce shoe stiffness within the participants. Before data collection, the time spent at each running technique may further affect the accuracy of the results. Therefore, with different views presented, there lies discrepancy in the efficacy of the running techniques.
The paediatric flatfoot refers to the complete or partial collapse of the foot’s arch (Nickel et al., 2018). The condition of flatfoot is common in both children and adults. It could be further divided into symptomatic flatfoot and asymptomatic flatfoot. The symptomatic flatfoot exhibits activities such as pain and limitation of activity whereas the asymptomatic flatfoot has little or no symptoms. In this respect, children with flatfoot exhibit some of the symptoms such as – outward tilting of the heel ,tenderness or cramping in the foot, reduced energy on participating in physical activities, difficulty with shoes. The X-rays helps in the assessment of the deformity. For the treatment of asymptomatic flatfoot, some of the non-surgical approaches may be required such as modifications of activities, providing orthotic devices which fit inside the shoe to provide support and improve function. For the treatment of symptomatic flatfoot physical therapies such as stretching exercises may be suggested, which could reduce the movement issues caused by flatfoot. In this respect, shoe modifications could also help correct the movement issues. For the management of pain suggesting medications such as ibuprofen could be helpful (Dars, Uden, Kumar & Banwell, 2018). The provision of the surgical interventions for the treatment of symptomatic flatfoot mainly depends upon the type of deformity; if the deformity is small light physiotherapy exercises is more than sufficient.
The paediatric foot orthoses can be prescribed under a number of conditions. Some of these have been discussed over here such as forefoot valgus deformity in children where the lateral forefoot loads first and the first metatarsal is the initial point of contact for the forefoot. The orthotic treatment over here aims at keeping the midtarsal joint maximal pronated. As mentioned by Lee, Kim, Kim and Hong (2017), the very first requirement is to access properly and prescribe the treatment method which is best suitable. There have been many speculations regarding the efficacy of suggesting the wearable devices to the children. it has been seen that orthotic treatments which help to correct a majority of the posture and movement difficulties are more efficient than wearable devices. As argued by Pratt and Sanner (2016), since the interventions are suggested for small children it has been found that the wearable devices are least preferred by them and makes the children uncanny and irritable.
It could be compared with functional foot orthoses which consist of a rigid plate, contouring to the plantar surface of the patient’s foot. It extends from the heel to the metatarsophalangeal joint and includes both forefoot and rearfoot posts. In the functional foot, orthosis pressure is applied to the foot to improve joint motions and assist in extrinsic and intrinsic foot musculature creating normal gait pattern.
Thus, before prescribing foot orthoses for paediatric children a number of factors need to be taken into consideration such as the age of the child undergoing the treatment, efficiency standards of the orthotic treatment based upon evidence based results, the willingness of the parents to support the orthoses procedure and the degree and position of deformity and are some of the important factors.
References
Acar, M. A., Güleç, A., Aydin, B. K., Erkoçak, Ö. F., Yilmaz, G., & ?enaran, H. (2015). Reconstruction of foot and ankle defects with a free anterolateral thigh flap in pediatric patients. Journal of reconstructive microsurgery, 31(03), 225-232. DOI: 10.1055/s-0034-1395888
Barton, C. J., Bonanno, D. R., Carr, J., Neal, B. S., Malliaras, P., Franklyn-Miller, A., & Menz, H. B. (2016). Running retraining to treat lower limb injuries: a mixed-methods study of current evidence synthesised with expert opinion. Br J Sports Med, 50(9), 513-526. Retrieved from: https://bjsm.bmj.com/content/50/9/513
Bixby, S. D., & Puig, S. (2018). Lower Extremity Injuries in Adults and Children: Evidence-Based Emergency Imaging. In Evidence-Based Emergency Imaging (pp. 477-496). Springer, Cham. Retrieved from: https://link.springer.com/chapter/10.1007/978-3-319-67066-9_31
Cranage, S., Banwell, H., & Williams, C. M. (2016). Gait and Lower Limb Observation of Paediatrics (GALLOP): development of a consensus-based paediatric podiatry and physiotherapy standardised recording proforma. Journal of foot and ankle research, 9(1), 8. Retrieved from: https://jfootankleres.biomedcentral.com/articles/10.1186/s13047-016-0139-4
Dars, S., Uden, H., Kumar, S., & Banwell, H. A. (2018). When, why and how foot orthoses (FOs) should be prescribed for children with flexible pes planus: a Delphi survey of podiatrists. PeerJ, 6, e4667. Retrieved from: https://peerj.com/articles/4667/?utm_source=TrendMD&utm_campaign=PeerJ_TrendMD_1&utm_medium=TrendMD
Landreneau, L. L., Watts, K., Heitzman, J. E., & Childers, W. L. (2014). LOWER LIMB MUSCLE ACTIVITY DURING FOREFOOT AND REARFOOT STRIKE RUNNING TECHNIQUES. International Journal of Sports Physical Therapy, 9(7), 888–897. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4275193/#B16
Lee, E. C., Kim, M. O., Kim, H. S., & Hong, S. E. (2017). Changes in Resting Calcaneal Stance Position Angle Following Insole Fitting in Children With Flexible Flatfoot. Annals of rehabilitation medicine, 41(2), 257-265. Retrieved from: https://doi.org/10.5535/arm.2017.41.2.257
Nickel, K. J., Van Slyke, A. C., Knox, A. D., Wing, K., & Wells, N. (2018). Tissue Expansion for Severe Foot and Ankle Deformities: A 16-Year Review. Plastic Surgery, 2292550317749510. Retrieved from: https://journals.sagepub.com/doi/abs/10.1177/2292550317749510
Pratt, D. J., & Sanner, W. H. (2016). Paediatric foot orthoses. The Foot, 6(3), 99-111. Retrieved from: https://sci-hub.tw/https://www.sciencedirect.com/science/article/pii/S0958259296900000
runnersworld.com (2018), runnersworld.com , Retrieved on 30 May 2018, from https://www.runnersworld.com/training/a20845352/study-rearfoot-forefoot-strike-equally-efficient/
Vannatta, C. N., Kernozek, T. W., & Gheidi, N. (2017). Changes in gluteal muscle forces with alteration of footstrike pattern during running. Gait & posture, 58, 240-245. DOI: https://doi.org/10.1016/j.gaitpost.2017.08.005
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